HomeMy WebLinkAboutMiscellaneous - 25 MORNINGSIDE LANE 4/30/2018 (2)77 L7 Date. v—�- ee .......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation
in the buildings of ............................
at ......
No Andover, Mass.
....
Fee. Lic. No... . FZ 3. � ....
GAS INSPECTOR U1010
Check #
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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City/Town: ! o _ 14 Ald- o MA. Date:_ Permit#
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Building Location: a'c 14,1R 't "V( , Owners Name: B ,i d it
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Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential c❑.-
Title
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: t[- Plans Submitted: Yes ❑ No ❑
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BASEMENT
15T FLOOR
2 FLOOR
3 FLOOR
4 FLOOR
5TH FLOOR
6 FLOOR
7 FLOOR
T'—FLOOR
Installing Company Name: �. r �,
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Check One Only Certificate #
AddressiQO L d k City/Town: 1/* --State:
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Business Tel: S ? � �ZV
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Name of Licensed Plumber/Gas Fitter:
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes E' No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy � Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner El Agent El
By checking this box ❑, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in
�••-••-- -••••• - •• • M...•�....� - I— Ana-�OWIu�e.w QLdLV rjumou %,oae ana tonapter lU of the General Laws.
Tye of License:
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Signature of Licens Plumber Gas Fitter
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License Number:
APPROVED OFFICE USE ONLY
Location 2:S
No. J Date 3 " 17
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NpRTM TOWN OF NORTH ANDOVER
„ Certificate of Occupancy $
i Building/Frame Permit Fee $
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CMEta Foundation Permit Fee $
SAUS
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•fir Permit Fee $ �S
Sewer Connection Fee $
Water Connection Fee $
TOTAL $19 2t
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Buildin Inspector
13770 03/27/9712:07 25.0
Div. Public Works
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